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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417825
Report Date: 05/24/2023
Date Signed: 05/24/2023 05:20:57 PM

Document Has Been Signed on 05/24/2023 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:BERKELEY YMCA EHS - VERA CASEYFACILITY NUMBER:
013417825
ADMINISTRATOR:GLORIA CROSS-BROOKSFACILITY TYPE:
830
ADDRESS:2246 MARTIN LUTHER KING JR WAYTELEPHONE:
(510) 542-2146
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 26TOTAL ENROLLED CHILDREN: 26CENSUS: 19DATE:
05/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Gloria Cross-BrooksTIME COMPLETED:
05:30 PM
NARRATIVE
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On May 24, 2023 at 12:32pm Licensing Program Analyst (LPA) Indira Loza arrived unannounced and met with Director Gloria Cross-Brooks. There were 19 infants present during today's visit and seven fingerprint cleared staff. LPA toured the facility for a Health and Safety check.

At 12:35pm LPA Loza observed a 9 month old infant sleeping on a rocker with a blanket. LPA informed the Director that infants are not allowed to sleep in rockers due to a high risk of their breathing being obstructed by the upright position and the blanket on the sleeping infant due to an increased risk of suffocation. This violates California Code of Regulations(CCR) 101223(a)(2). LPA also informed the Director that rockers are not allowed on the premises, which violates Health and Safety Code(HSC) 1596.846(b) and (c).

See 809-D for one Type A deficiency and one Type B deficiency.

Facility shall post a copy of the report in a location where all parents can easily view it. All parents of currently enrolled and newly enrolled children during the next twelve months must sign an LIC9224 acknowledgement form and place in each child's file.

An exit interview was conducted with Director Gloria Cross-Brooks.
Report and Appeal Rights provided.
Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 05:20 PM - It Cannot Be Edited


Created By: Indira Loza On 05/24/2023 at 04:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BERKELEY YMCA EHS - VERA CASEY
FACILITY NUMBER: 013417825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
101223(a)(2)

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Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights:...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Director shall study the Safe sleep regulations, and email the LPA a plan to implement the regulations no later than May 25, 2023.
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Based on observation, record review, and interview it was determined that an infant was sleeping on a rocker which was slanted upright, with a blanket covering the child. This poses an immediate risk to the Health and Safety of the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 05:20 PM - It Cannot Be Edited


Created By: Indira Loza On 05/24/2023 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BERKELEY YMCA EHS - VERA CASEY
FACILITY NUMBER: 013417825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited
HSC
1596.846(b)and(c)

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HSC1596.846: (b) A baby walker shall not be kept or used on the premises of a child day care facility (c) A "baby walker" means any article described in paragraph 4 of subdivision (a) of section 1500.86 of part 1500 of title 16 of the code of Federal Regulations. This requirement was not met
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The Director shall remove the baby bouncer from the premises, no later than 5/25/23.
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as evidenced by: Based on observation it has been determined that a baby walker was in Room 1, which poses a potential Health and Safety risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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